Board review - Viral infections

Rubeola (nine-day or red measles)

* Prodromal symptoms - fever, malaise, dry (occasional croupy) cough, coryza, conjunctivitis c clear d/c, marked photophobia
* 1-2 days p prodromal symptoms - Koplik spots on the buccal mucosa
* Koplik spots - tiny, bluish-white dots surrounded by red halos

rubeola (nine-day or red measles)

* Day 3 or 4 - blotchy, erythematous, blanching, maculopapular exanthem appears
* Rash begins at the hairline and spreads cephalocaudally and involves palms and soles
* Rash typically lasts 5 - 6 days
* Can see desquimation in severe cases

rubeola (nine-day or red measles)

* Patients can be systemically ill
* Incubation period 9-10 days
* Patients contagious from 4 days prior to the rash until 4 days after the resolution of the rash
* Highly contagious - 90% for susceptible people

rubeola (nine-day or red measles)

* High morbidity and mortality common in children in underdeveloped countries
* Peak season is late winter to early spring
* Potential complications - OM, PNA, obstructive laryngotracheitis, acute encephalitis
* Vaccination is highly effective in preventing disease

rubeola (nine-day or red measles)

Rubella (german measles)

* Little or no prodrome in children
* In adolescents - 1-5 days of low-grade fever, malaise, headache, adenopathy, sore throat, coryza
* Exanthem - discrete, pinkish red, fine maculopapular eruption - begins on the face and spreads cephalocaudally
* Rash becomes generalized in 24 hours and clears by 72 hours

rubella (german measles)

* Forchheimer spots - small reddish spots on the soft palate - can sometimes be seen on day 1 of the rash
* Arthritis and arthralgias - frequent in adolescents and young women - beginning on day 2 or 3 lasting 5-10 days
* Up to 25% of patients are asymptomatic - serology testing may be necessary to establish the diagnosis

rubella (german Measles)

* Important in establishing the diagnosis if the patient is pregnant or has been in contact c a pregnant woman
* Peaks in late winter to early spring
* Contagious from a few days before the rash to a few days after the rash
* Incubation period 14-21 days
* Complications - rare in childhood - arthritis, purpura c or s thrombocytopenia, mild encephalitis

rubella (german Measles)

Varicella (chickenpox)

* Caused by varicella-zoster virus
* Highly contagious
* Brief prodrome of low-grade fever, URI symptoms, and mild malaise may occur
* Rapid appearance of puritic exanthem

varicella (chickenpox)

* Lesions appear in crops - typically have 3 crops
* Crops begin in trunk and scalp, then spread peripherally
* Lesions begin as tiny erythematous papules, then become vesicles surrounded by red halos
* Lesions began to dry - umbilicated appearance, then surrounding erythema fades and a scab forms

varicella (chickenpox)

* Hallmark - lesions in all stages of evolution
* All scabs slough off 10-14 days
* Scarring not typical unless superinfected
* Cluster in areas of previous skin irritation
* Puritic lesions on the skin
* Painful lesions along the oral, rectal, and vaginal mucosa, external auditory canal, tympanic membrane

varicella (chickenpox)

* Occurs year-round, peaks in late autumn and late winter through early spring
* Incubation period ranges from 10-20 days
* Contagious 1-2 days prior to rash until all lesions are crusted over
* Complications - secondary bacterial skin infections (GAS), pneumonia, hepatitis, encephalitis, Reye syndrome

varicella (chickenpox)

* Severe in the immunocompromised host - can be fatal
* Can have severe CNS, pulmonary, generalized visceral involvement (often hemorrhagic)
* Need to get varicella-zoster immunogloblin 96 hours post-exposure to possible varicella

varicella (chickenpox)

Adenovirus

* 30 distinct types
* Variety of infections including conjunctivitis, URIs, pharyngitis, croup, bronchitis, bronchiolitis, pneumonia (occ fulminant), gastroenteritis, myocarditis, cystitis, encephalitis
* Can be accompanied by a rash - variable in nature
* Typically can see - conjunctivitis, rhinitis, pharyngitis c or s exudate, discrete, blanching, maculopapular rash

adenovirus

* Can see anterior cervical and preauricular LAD, low-grade fever, malaise
* Peak season is late winter through early summer
* Contagious during first few days
* Incubation period 6-9 days

Coxsackie hand-foot-and-mouth disease

* Brief prodome - low-grade fever, malaise, sore mouth, anorexia
* 1-2 days later, rash appears
o Oral lesions - shallow, yellow ulcers surrounded by red halos
o Cutaneous lesions - begin as erythematous macules then evolve to small, thick-walled, grey vesicles on an erythematous base

Coxsackie hand-foot-and-mouth disease

* Highly contagious
* Incubation period 2-6 days
* Lasts 2-7 days
* Peak season summer through early fall
* If no cutaneous lesions - herpangina
o less painful and less intense than herpes gingivostomatitis

erythema infectiosum (fifth disease)

* Caused by Parvovirus B19
* Affects preschool and young school aged children
* Peak incidence in late winter and early spring, but it is seen year round
* Characterized by rash - large, bright red, erythematous patches over both cheeks - warm, but non-tender

erythema infectiosum (fifth disease)

* Facial rash fades, then see a symmetrical, macular, lacy, erythematous rash on the extremities
* Resolution occurs within 3-7 days of onset
* Transmitted by respiratory secretions, replicates in the RBC precursors in the bone marrow
* Can cause aplastic crisis in patients with sickle cell disease, other hemogloblinopathies, and other forms in hemolytic anemia

erythema infectiosum (fifth disease)

roseola infantum (exanthem subitum)

* Febrile illness affecting children 6-36 months
* Human herpesvirus 6 is causative agent
* Symptoms include:
o fever, usually >39
o anorexia
o irritability
o these symptoms subside in 72 hours

roseola infantum (exanthem subitum)

* As fever defervenscences, usually an erythematous, maculopapular rash that appear on the trunk and then spread to the extremities, face, scalp, and neck
* Occurs year-round
* More common in late fall and early spring
* Incubation period thought to be 10-15 days

roseola infantum (exanthem subitum)

Infectious mononucleosis

* Acute self-limiting illness of children and young adults
* Caused by EBV
* Transmission by oral contact, sharing eating utensils, transfusion, or transplantation
* Incubation period 30-50 days (shorter, 14-20 days, in transfusion-acquired infection)
* Don’t usually see “classic mono” in young children

Infectious mononucleosis

* Prodrome - fatigue, malaise, anorexia, HA, sweats, chills lasting 3-5 days
* Symptoms
o fever - can have wide daily fluctuations
o pharyngitis c tonsillar and adenoidal enlargement c or s exudate, halitosis, palatal petechiae
o LAD - anterior cervical and posterior cervical - in classic cases, generalized LAD toward end of wk 1

Infectious mononucleosis

* Symptoms cont:
o splenomegaly - develops in 50% of patients in 2nd-3rd wk
o hepatomegaly in 10% of patients
o exanthem - erythematous, maculopapular, rubelliform rash in 5-10% of patients

Infectious mononucleosis

* Complications:
o pneumonia
o hemolytic anemia and thrombocytopenia
o icteric hepatitis
o acute cerebellar ataxia, encephalitis, aseptic meningitis, myletis, Guillain-Barre
o rarely myocarditis and pericarditis

Infectious mononucleosis

* Complications cont:
o upper airway obstruction from tonsillar and adenoidal enlargement
# seen more often in younger patients
# children < 5 yrs of age c obstruction are more likely to have secondary OM, recurrent bouts of OM, tonsillitis, and sinusitis
o splenic rupture

Infectious mononucleosis

* Diagnosis:
o classic finding - lymphocytosis (50% or more) c 10% atypical lymphocytes
o 80% or more of patients c elevated liver enzymes
o Monospot - detects heterophil antibodies - specific, not as sensitive - 85% of adolescents + and fewer younger patients
o specific EBV antibody titers and PCR

Infectious mononucleosis

* DDx
o If fever and exudative tonsillitis predominate
# GAS, diphtheria, viral pharyngitis
o If LAD and splenomegaly predominate
# CMV, toxo, malignancy, drug-induced mono
o If severe hepatic involvement
# viral hepatitis, leptospirosis

herpes simplex infections

* Primarily involve the skin and mucous surfaces
* Can be disseminated in neonates and immunocompromised hosts
* Produces primary infection - enters a latent or dormant stage, residing in the sensory ganglia - can be reactivated at any time

herpes simplex infections

* HSV-1
+ >90% of primary infections caused by HSV-1 are subclinical
+ more common
* HSV-2
+ usually the genital pathogen
+ usual pathogen of neonatal herpes

herpes simplex infection

* Diagnosis
o usually made clinically
o can scrap base of vesicle and a special stain - Giemsa-stained (Tzanck)
# ballooned epithelial cells c intranuclear inclusions and multinucleated giant
o viral cultures take 24-72 hours

Primary herpes simplex infections

* Herpetic gingivostomatitis
o high fever, irritability, anorexia, mouth pain, drooling in infants and toddlers
o gingivae becomes intensely erythematous, edematous, friable and tends to bleed
o small yellow ulcerations c red halos seen on buccal and labial mucosa, tongue, gingivae, palate, tonsils

primary herpes simplex infections

* Herpetic gingivostomatitis
o yellowish white debris builds on the mucosal surfaces causing halitosis
o vesiculopustular lesions on perioral surfaces
o anterior cervical and tonsillar LAD
o symptoms last 5-14 days, but virus can be shed for weeks following resolution

primary herpes simplex infections

* Skin infections
o fever, malaise, localized lesions, regional LAD
o direct inoculation (usually cold sores)
o lesions are deep, thick-walled, painful vesicles on an erythematous base - usually grouped, but may be single
o lesions evolve over several days - pustular, coalesce, ulcerate, then crust over

primary herpes simplex infections

* Skin infections
o most common sites are lips and fingers or thumbs (herpes whitlow)
o eyelids and periorbital tissue infection can lead to keratoconjunctivitis - dx by dendritic ulcerations on slit lamp exam
# can lead to visual impairment - consult ophtho

Eczema herpeticum (kaposi varicelliform eruption)

* Onset of high fever, irritability, and discomfort
* Lesions appear in crops in areas of currently or recently affected skin (for those with atopic eczema or chronic dermatitis)
* Lesions begin as pustules, then rupture and crust over the course of a couple of days
* Lesions can become hemorrhagic

Eczema herpeticum (kaposi varicelliform eruption)

* Multiple crops can appear over 7-10 days (like varicella)
* Can be mild or fulminant, depending (in part) on the underlying dermatitis
* If area of involvement is large, can be lots of fluid loss and potentially fatal
* Treat promptly c acyclovir
* Risk of secondary bacterial infections

Eczema herpeticum (kaposi varicelliform eruption)

Recurrent herpes simplex infection

* Triggers include fever, sunlight, local trauma, menses, emotional stress
* Seen most commonly as cold sores
* Prodrome of localized burning, itching or stinging before eruption of grouped vesicles

recurrent herpes simplex infection

* Vesicles contain yellow, serous fluid and are often smaller and less thick-walled than the primary lesions
* Vesicular fluid becomes cloudy after 2-3 days, then crusts over
* Regional, tender LAD

herpes zoster (shingles)

* Caused by varicella-zoster virus
* After primary infection, virus lies dormant in genome of sensory nerve root cell
* Postulated triggers include mechanical and thermal trauma, infection, debilitation as well as immunosuppression
* Lesions are grouped, thin-walled vesicles on an erythematous base distributed along the course of a spinal or cranial nerve root (dermatome)

herpes zoster (shingles)

* Lesions evolve from macule to papule to vesicle then crusted over a few days
* May have associated nerve root pain - not common in pediatrics - usually short-lived unless it involves a cranial nerve root dermatome
* +/- fever or constitutional symptoms
* Regional LAD common

herpes zoster (shingles)

* Thoracic, cervical, trigeminal, lumbar, facial nerve dermatomes (order of frequency)
* If cranial nerve involvement - prodrome of severe HA, facial pain, or auricular pain prior to the eruption
* Affected patients can transmit varicella, but less of a problem b/c lesions are often covered by clothing and the o/p is not involved in most cases

herpes zoster (shingles)

gianotti-crosti syndrome

* Papular acrodermatitis
* Associated c amicteric hepatitis B, EBV, echovirus, coxasckievirus, parainfluenza virus, CMV, and RSV
* Most patients between 1-6 years old (range 3 months to 15 years)
* Prodrome of low-grade fever and malaise
* May be associated c generalized LAD, hepatomegaly, URI symptoms, and diarrhea

gianotti-crosti syndrome

* Lesions appear within a few days - discrete, firm, lichenois papules c flat tops ranging from 1-10 mm (larger in infants and smaller in older children)
* Papules can be flesh colored, pink, red, dusky, coppery, or purpuric
* Distributed symmetrically over extremities (including palms and soles), buttocks, and face - relative sparing of the trunk and scalp
* No mucosal involvement and non-purtitic

gianotti-crosti syndrome

* Usually clears in 2-3 weeks, but can last for 8 weeks or more
* Lab studies are generally non-specific, but liver enzymes should be obtained and if abnormal - hepatitis B or EBV serology should be done
* Treatment is supportive
* Steroid creams contraindicated b/c they can make the rash worse

gianotti-crosti syndrome

Board review - Viral infections.ppt

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Pediatric Urology- Gynecology

Pediatric Urology- Gynecology
By:Keith Wilkinson, MD FACEP

Anatomy
Shaft
Corpus Cavernosum (two)
* Two large columns on penile dorsum
* Columns separated by septum of fibers
Corpus spongiosum
* Located on ventral side (underside) of penis
* Does not contribute to penile rigidity
* Contains urethra
Tunica albuginea
* Bands together the two columns of corpus cavernosa
Lacunar space (Space of Smith)
* Surrounds tunica albuginea
* Intralacunar smooth muscle found within space

Anatomy
Glans
Innervation-
Sensation-
Pudendal nerve supplies dorsal nerves to penis
Erectile function- Nerves course through corpus cavernosa
Parasympathetic input (excitatory)- “Point”
Nervi erigentes runs adjacent to prostate gland
Sympathetic input (inhibitory)- “Shoot”
Sympathetic nerves supplied by thoracolumbar plexus
Vascular Supply of the Penis
Arterial inflow
Branches of deep internal pudendeal arteries

Hypospadias
* Incomplete development of the anterior urethra
o Anterior- (50 %)- Distal 1/3rd ventral shaft
o Middle- (20 %) percent of cases)- Middle 1/3rd
o Posterior hypospadias (30%)- Proximal 1/3rd
* More common in caucasians (esp Italians, Jews)
* Hypospadias, chordee associated with undescended testes and inguinal hernia (9- 17%)
o Abnormalities of the higher urinary tract are infrequent
* Treatment
o Single stage repair at age 6-18 months

Phimosis
* Previously retractable foreskin no longer retractable or foreskin retraction doesn’t occur by puberty
* Most retract by 1 year with 80% by age 4
* Rare in children
* Circumcision, repeated trauma, infections, poor hygiene, or chemical irritation
* Kids more likely to have obstruction
o Adults present with pain
* Surgery for obstruction of urinary stream, recurrent UTI or bouts of balanoposthitis

Phimosis
* Treatment
o Rare- only required for retention, possible prepuce abscess
o Urinary retention
+ Tub urination
+ Place feeding tube
+ Suprapubic aspiration safe, temporary
o Dorsal slit
+ Dorsal block or collar block
+ Double hemostat crush swollen prepuce
+ Incise between hemostats
+ Close open ends with absorbable suture
* Inability to extend foreskin back over glans
* Less common than phimosis
* Much more common in adults than kids
* More pressing than phimosis
* Often iatrogenic
* Therapy
o Pain management-
+ Topical 2% lidocaine gel or EMLA (eutectic mixture of local anesthetics cream [2.5% prilocaine, 2.5% lidocaine]
+ Systemic analgesia, dorsal penile nerve block, ring block
+ 1-5 cc lidocaine without epi
# 1/2 at 10:00 and 2:00 position at shaft base
# Inject between Buck’s fascia and corpora
o Control of edema-
+ Granular sugar to the surface of the swollen foreskin, cover with a condom or a finger of a rubber glove
+ Cool, compressive 1-in Surgical Cling dressings wrapped distal to proximal
+ Cooled with ice water-filled latex examination gloves
* Therapy
o Direct circumferential manual compression
o Hyaluronidase
+ 1 mL of hyaluronidase (150 U/cc Wydase) injected via TB syringe directly into several sites of the edematous foreskin
+ Breaks down hyaluronic acid in connective tissue, enhances fluid diffusion between tissue planes
+ Almost immediate decreased swelling
o Manual reduction
+ Distal traction of the foreskin using index and third fingers
+ Thumbs push the glans penis back through the paraphimotic ring of the foreskin
o Dorsal slit

Balanitis
Inflammation of the glans
* More common in men than boys
* Causes

Uncircumcised, poor hygiene
Chemical irritants (soap, petroleum jelly)
Drug allergies (tetracycline, sulfonamide)
Morbid obesity
Candidal species
Group A and B streptococci, Staph.,
Trichomonal species
Herpes Simplex
* Recurrent bouts can lead to phimosis

Balanitis
* Testing
o Serum glucose
o Culture of discharge
o Wet mount for Candida
o Syphilis serology test if STD suspected
o Herpes PCR swab
o Gonorrheal, chlamydia in adolescent, suspicion of abuse
* Treatment
o Retract the foreskin daily and soak in warm water to clean penis and foreskin
o Apply Bacitracin (not Neosporin)
o Apply topical clotrimazole for probable candidal balanitis

Balanoposthitis
* Inflammation of the glans and foreskin
* Etiology- uncircumcised, usually preschoolers
o Infection-
+ Grp A Strep (thin, purulent discharge; rapid strep positive), Staph, Candida, rarely gram negatives, syphilis (adolescents)
o Chronic friction, zipper injuries, and contact dermatitis, or a fixed drug eruption (TCN, or clotrimazole)
o Chronic- Balanitis xerotica obliterans
* Treatment-
o Local hygiene (sitz baths, cleaning)
o 0.5% hydrocortisone cream to the affected parts
o Antimicrobial topical ointments
+ Utility is unproved
o Oral antibiotics
+ 5 to 7 days of amoxicillin or cephalexin in recalcitrant cases or with more advanced cellulitis
+ Recurrence raises suspicion of DM, immunocompromise, Balanitis xerotica obliterans

Pearly Papules
* Common- seen in 30%
o Most common in young, uncircumcised African- Americans
* Empty hair follicules on the corona
* Benign- Do not warrant treatment
o Don’t resolve with circumcision
* Can be confused with (genital warts)

Meatal Stenosis
* Circumcised males
* Follows inflammatory reaction around meatus
o Usually diaper rash
* Significant when sprays or dorsally deflects stream
* Obstruction, dysuria, UTI uncommon
o Tub voids, urologic consultation
o Foley catheter, urethral meatotomy
Priapism
* Can occur in any age group
o Peaks at age 5-10 years, 20-50 years
* Causes
o Erectile dysfunction drugs most common causes of adult priapism (0.05-6% of users)
o Sickle cell most common cause in children
+ Causes 2/3rd of all cases
+ Occurs in 27% male children, 89% male adults
+ Highest aged 19-21 years
* Duration of symptoms most important factor affecting outcome
o Up to 92% with priapism for less than 24 hours remained potent
o Only 22% with priapism that lasted longer than 7 days remained potent
* Erection-smooth muscle relaxation and increased arterial flow into the corpora cavernosa
o Engorgement of the corpora cavernosa causes compression of the venous outflow tracts (ie, subtunical venules), resulting in blood trapping within the corpora cavernosa.
o Nitric oxide- major neurotransmitter controlling erection
+ Corpora cavernosa endothelium lining secretes nitric oxide

* Priaprism - failure of detumescence
+ Underregulation of arterial inflow (ie, high flow)
+ Failure of venous outflow (ie, low flow)- more common
# Excessive release of neurotransmitters
# Blockage of draining venules (eg, mechanical interference in sickle cell crisis, leukemia, or excessive use of IV TPN
* Treatment
o Impotence uncommon
o Need for surgical decompression uncommon
o Most low- flow, resolves spontaneously
o Hydration, analgesia
* Sickle cell disease
o Analgesics, hydration
o Exchange transfusion
+ Aim for reduction of Hgb S to 30- 35%
+ Aim for HCT > 30%
o Medical therapy successful up to 37%Alpha, beta agonists
o Oral pseudoephedrine or oral beta-agonists- (terbutaline) little efficacy
* Penile nerve block
o Bupivicaine without epi
* Intercavernosal phenylephrine (Neo-Synephrine)- drug of choice
o Nearly pure alpha agonist
o Intracavernosal injection
o 1 mL:1000 mcg diluted with an additional 9 mL NS
o Inject 0.3-0.5 ml using a 29-gauge needle into the corpora cavernosa
o Compress area of injection
o Wait 10-15 minutes between injections

Penile decompression
* Repeated aspirations or irrigations and sympathomimetic injections over several hours might be necessary
* Resolution of ischemic priapism following sympathomimetic injection with or without irrigation has been shown to occur in 43-81%
* Aspiration- 16- to 18-gauge angiocath into the lateral aspect of the corpus cavernosum
o Unilateral approach usually adequate because of the vascular channels between the 2 corpora cavernosa
o May be difficult because of the sludging of blood within the corpus cavernosum
o Saline irrigation and repeated aspirations may improve flow dynamics
* Surgical decompression
* Phenylephrine irrigation
o 1000 mcg phenylephrine in 100 mL of normal saline (10 mcg/mL)
o Infuse 10-20 mL at a time
o If unable to infuse, inject phenylephrine directly in 200- to 500-mcg aliquots
o Maximum dose of 1500 mcg
o Compression must be applied
o Epinephrine can also be used

Penile Trauma
* Zipper injury
o Local anesthetic
o Cute median bar with wire cutters
* Corporal rupture
o Adolescents, teens, adults
o Palpable, audible snap
o Acute bending of the penis
o Acute pain, immediate detumescence
o Delayed presentation common
o Treatment
+ Exploration
* Shaft laceration
o Exclude corporal, uretheral injuries
o Close with absorbable suture
* Toilet seat most common
o Corporal, urethral injury uncommon
o Meatal blood warrants consultation, consideration for retrograde urethrogram

Scrotal Pain by Age
* Acute scrotal pain seen in the ED
o Torsion of an appendage was the most common diagnosis (46%)
+ Especially age 3- 13
o Epididymitis next (35%)
+ Most common after age 13
o Testicular torsion (16%)
+ Most common cause in first year (86%)

Testicular Torsion
* Failure of fixation between enveloping tunica vaginalis and posterior scrotal wall
o Inappropriately high attachment of the tunica vaginalis
o Bell clapper deformity- found in up to 12% of males
* Left testicle more common
o Bilateral in 10%
* Most aged 12-18 years (peak age 14)
o Smaller peak also occurs in neonatal period in undescended or incompletely descended testes
* Most testes torse lateral to medial
o Typically takes 720 degree turn for ischemia
* Approximately 5-10% of torsed testes spontaneously detorse

Testicular Torsion
* Pain usually sudden, severe
o Scrotum, inguinal region, lower abdomen
* History of physical activity, or trauma
o Fair number occur during sleep
* Up to 50% of patients have prior episodes of intermittent testicular pain
o Nausea and vomiting (20-30%)
o Abdominal pain (20-30%)
o Fever (16%)
o Urinary frequency (4%)
* Elevated, horizontal lie of the testicle- (Brunzel sign)-
o Best seen in upright position
* Skin pitting at scrotal base- (Ger sign)
* Enlargement and edema of the testicle, scrotum
* Scrotal erythema
* Ipsilateral loss of the cremasteric reflex
o As high as 100% in some series
* Abnormal contralateral testicle

Testicular Torsion
* Diagnosis
o Urinalysis- usually normal
+ WBCs can be seen in up to 30%
o CBC-
+ Mildly elevated in most (60%)
o Doppler US/ nuclear scan
+ Sensitivity of 86%, specificity of 100%, accuracy of 97% when presence of intratesticular flow is the sole criterion
+ Nuclear scan- nearly identical sensitivity (80- 90 %), specificity (75- 95 %)
Testicular Torsion
* Treatment
o Surgical exploration
o Manual detorsion
+ Manual detorsion is successful in 30-70% of patients
+ “Open the book” -

Testicular/ Epididymal Appendage Torsion
* Appendages have no known function
o Appendage testes seen in 92%, epididymal 25%
* Most common cause of acute scrotum
* Peak age 7- 14 (mean 10.6)
* Pain is more intense near the head of the epididymis or testis
* Isolated tender nodule may be palpated
* “Blue dot sign” pathognomonic- 21%
* Treatment-
o Testicular doppler US if unsure
o Most will calcify or degenerate over 10 to 14 days and cause no harm

Epididymitis
* Pain usually more gradual than torsion
o Gradual onset, teens, older kids
* Causes-
o Congenital anomalies of the lower urinary tract
o Retrograde reflux of urine
o STDs in sexually active > 15
+ Neisseria gonorrhoeae, Chlamydia trachomatis
+ Escherichia coli with reflux disease
+ Klebsiella pneumoniae, Pseudomonas aeruginosa in neurogenic bladder, CP
* Presentation-
o Epididymal tenderness
+ Sterile pyuria, especially in first 15 cc void
o Cremasteric reflex preserved
o Prehn’s sign of low utility
* Diagnosis- Ultrasound
o Enlarged epididymis
o Increased flow
o Flow to testicle
* Treatment-
o Outpatient management
o Oral antibiotics for 10 to 14 days
+ Sexually active
# Need to cover GC, chlamydia, ureaplasma, mycoplasma
# Ceftriaxone, azithromycin
# Consider test for syphilis in sexually active
+ Suspected bacterial
# E. Coli usual pathogen
# Ampicillin, ceftriaxone, gentamicin if toxic
# Amoxicillin, TMP-SX if non-toxic
Mumps
* Most common cause of primary orchitis
* Droplet spread
o As contagious as influenza
* Symptoms 2- 3 weeks after exposure
o Up to 20% asymptomatic
* Uneventful recovery in 2 weeks
* Complications
o Orchitis- Occurs in 20% of symptomatic
+ Swelling of one or both testicles
+ Painful, but rarely leads to sterility
+ Typically unilateral
o Pancreatitis- upper abdominal pain, N/V
o Encephalitis/ meningitis- rare
o Ovarian inflammation- fertility unaffected
o Hearing loss- rare, usually permanent

Orchitis
* Rare
* Bilateral testicular tenderness and swelling over a few days´ duration
* Occurs in conjunction with systemic diseases
o Mumps- occurs on 20% prepubertal (rarely postpubertal)
+ Follows the development of parotitis by 4-7 days
+ Unilateral in 70% of cases
+ Described with MMR vaccine
o Other viral illnesses-
+ Coxsackie virus, infectious mononucleosis, varicella, and echovirus.
o Bacterial orchitis rare
+ Almost always associated with spread from epididymitis
+ Nearly always in sexually active - Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli
+ Unilateral testicular edema occurs in 90% of cases.
* Treatment-
o Symptomatic if concurrent with virus (mumps, mononucleosis)
+ Unilateral testicular atrophy occurs in 60% of patients with orchitis, sterility rare
o Urology evaluation, ultrasound if toxic, diagnosis unclear, suspicion of bacterial orchitis

Undescended Testes
* Testes start descent from inguinal ring at 7th month, complete by birth
* Retractile testes more common
o Cremasteric muscle pulls testicle up
o Should be able to be drawn down into scrotum
+ “Catcher’s position”
o Typically resolves by adolescence
* True, undescended seen in 4% newborn males
o More common in preemies
o Decreases to 0.8% by 1 year
+ Increased risk torsion, trauma, malignancy, infertility
+ Should be corrected if not in normal position by age 1
Scrotal Problems
* Hydroceles
o Incomplete or abnormal obliteration of the processus vaginalis
o Scrotum communicates with abdominal cavity
+ Can lead to diagnostic confusion with appendicitis
o Painless, apparent in neonatal period, disappear by 1 year of age
o Non or minimally compressible scrotal fullness that transilluminates
o US for pain, inability to find testicle, possibility of intratesticular tumor
o Compressibility suggests communicating hydrocele- concurrent inguinal hernia
* Varicoceles-
o Dilated network of veins of pampiniform plexus
o Consequence of spermatic venous valvular incompetence
o Often not noticed until puberty
* Found on the left side (85- 90 %)
o Left spermatic vein drains directly into renalvein
o “Bag of worms” mass posterior, lateral, and superior to the testis extending up the spermatic cord
* Significance
o Untreated can reduce fertility
+ Smaller, softer testicle
o Acute onset, persistence of varicocele when child lies down can suggest rare acute increase in IVC or renal vein pressure (Wilm’s tumor)
* Spermatoceles and Epididymal Cysts
o Sperm-containing cysts of the rete testis or efferent ducts (spermatoceles) or the epididymis (epididymal cysts)
o Painless scrotal masses
+ Located superior and posterior to the testes
+ Transilluminate well
o US shows anechoic mass without disruption of testicle parenchyma
o Treatment-
+ Reassurance- no impact on fertility
+ NSAIDS

Idiopathic Scrotal Edema
o Painless scrotal erythema, induration
+ Nontender, may itch
+ Can extend to portions of the penis, abdomen, and groin
+ No fever
o Occurs in 2- 11 year olds
o Two-thirds of cases unilateral
o No cause known
+ Differential includes cellulitis, local contact dermatitis, insect bite, fixed drug eruption
o Management-
+ US if unable to examine testes
+ U/A, WBC normal
+ No benefit from steroids, antihistamines, antibiotics
+ Usually resolves in 1- 4 days
+ Recurrence rate up to 20%
Kidney Stones
* Children <16 constitute ~ 7 % of all cases of stones
* 1:1 sex distribution
* Can present at any age- most common age 8-10
* 20- 30 % of children may have only painless hematuria
* Incidence higher in southeast US, hot climates, family history
* Types
o Calcium with phosphate or oxalate (57%)
o Struvite (24%)- associated with infection
o Uric acid (8%)
o Cystine (6%)
* Diagnosis
o Hematuria
+ Spot urine for Spot urinalysis and culture, including ratio of calcium, uric acid, oxalate, cystine, citrate, and magnesium to creatinine
o Helical CT still performs well (97% sensitive, 96% specific)
o Ultrasound better in kids than adults
+ Can be used as first study but still not as good as CT
* Disposition
o Urologic consult
o Admit infants, infected stones, lone kidney, intractable pain, abnormal kidney function, larger stones

Gynecologic Problems
* Labial Adhesions
o Also called vulvar synechiae, gynatresia, vulvar or labial fusion, labial coalescence, agglutination
o Usually seen in girls 3 months to 6 years of age
o Common-
+ Accounts for nearly 50 % of prepubertal gynecologic outpatient complaints
+ Usually asymptomatic
# May have urethritis, UTI
* Labial Adhesions
o Appearance
+ Fusion thin, affects labia minora, doesn’t involve clitoris
+ If thick, may be midline fusion of the labioscrotal folds (median raphe) seen in ambiguous genitalia
o Management
+ Requires no treatment (resolves spontaneously during puberty)
+ Topical estrogen cream (0.1% conjugated estrogen vaginal cream) twice daily for 2 to 4 weeks

* Lichen Sclerosis Atrophica
o Uncommon in prepubertal girls
o Presents with itch, irritation, dysuria, perineal and/or perianal pain, and
bleeding
o May be a coexistent vaginal discharge
o Characteristic appearance- white, atrophic, finely wrinkled vulva
+ Ulcerations, blisters, excoriations, and
inflammation are seen over the vulva, perineum, and perianal area
+ Hourglass or figure-eight pattern
* Lichen Sclerosis Atrophica
o Management
+ Removal of all perineal irritants
+ Systemic antipruritics
+ Local application of an emollient ointment, such as A & D ointment
+ Topical steroids- 2- to 3-month course of treatment with a low-potency topical
steroid cream, such as 2.5% hydrocortisone cream, applied two
to three times daily, is often useful
+ Topical antifungal creams, systemic antibiotics for superinfection
* Urethral prolapse
o Uncommon disorder
o Circular eversion of urethral mucosa through the urethral meatus
o Almost all (90- 100 %) cases occur in black girls
o Etiology unclear
o Typically presents with painless “vaginal”
bleeding
o Doughnut-shaped mass originating from and encircling the urethral meatus, protrudes through the vulva
+ Edematous and friable, often ulcerated
* Urethral prolapse
o Treatment
+ Identify the urethral meatus with certainty
# Observing the child voiding her bladder or by catheterization
+ Don’t confuse with sexual abuse
+ Mild prolapse
# Sitz baths, topical antibiotics, topical steroids, topical estrogen cream (0.1% conjugated estrogen cream to the prolapsed urethra 2-3 times daily for 2 weeks)
# Urologic referral
# Simple manual reduction and urethral catheterization for 1-2 days have been effective in minor cases of urethral prolapse; however, recurrence rates are high
* Urethral foreign bodies
o Bloody urine combined with infection and slow, painful urination should
suggest a possible foreign body in the lower urinary tract
o Management-
+ X- ray of the bladder and urethral areas may show opaque foreign body
+ Endoscopic removal
+ Retrograde urethrography or endoscopic confirmation of an intact, nontraumatized urethra is indicated after removal

Gynecologic Problems Vaginitis
* Affects vulva predominantly in prepubertal girls
* Atrophy from estrogen lack, acidic pH, lack of lactobacilli, poor hygiene
* Most nonspecific- negative cultures or mixed flora
* Group A beta-hemolytic streptococci (GABHS) occasionally causes a beefy red, painful vulvovaginitis
* Shigella also described
o Up to 18% in one study
* Pinworm infection with Enterobius vermicularis is common in prepubertal children
o May present with significant vulvar pruritus, more familiar anal pruritus.
* Candida albicans most frequent fungal
* Noninfectious etiologies- chemical irritation from lotions and bubble baths
* Systemic skin disorders- seborrhea, lichen sclerosis, psoriasis, eczema, and contact dermatitis
* Treatment
o Need to suspect vaginal foreign body
o Supportive care for nonbacterial
+ Wiping front to back
+ Avoidance of tight-fitting garments
* Neonatal vaginal bleeding
o Usually occurs at 3 to 5 days
o Caused by withdrawal of transplacental estrogens
o No treatment except reassurance of parents.

* Hydrocolpos
+ Uterine distension from imperforate hymen, transverse vaginal septum, or atretic vagina
+ Bulging, shiny, pearly gray “mass” is seen covering the introitus
+ Palpable abdominal mass
+ Possible urinary retention
o Diagnosis
+ US- nonmobile, midline, cystic mass behind the bladder
o Treatment
+ aspiration and drainage

Pediatric UTI
* Neonatal period-
o UTI in 4- 7% of febrile infants
o Hematogenous seeding of kidneys
* Postneonatal period-
o UTI in 2% of age 1-5
o 3-5% of school aged girls
o Retrograde migration of perineal flora
* Congenital urinary tract anomalies-
o vesicoureteral reflux, urolithiasis
associated with a higher incidence
* Bacteria-
o Escherichia coli accounts for vast majority
o Klebsiella, Proteus, Enterobacter species
o Enterococcus species, Staphylococcus aureus, and group B streptococci
+ Most frequently isolated gram-positives
+ More likely to be causative organisms in the
neonatal period
o Coagulase-negative staphylococcal UTI occurs in teens and young adults
o Other agents
+ Adenovirus cystitis occurs more commonly in young boys
* Testing
o Urine culture gold standard
o Sensitivities of a positive leukocyte esterase or nitrite or a positive urine culture result < 50%
o Combined presence of pyuria (more
than five WBC/ hpf) and bacteriuria
improves sensitivity to 65%
o Positive predictive value of UA is 81 %
* Treatment- 10- to 14-day course in children
* Disposition
o Inpatient management for any child less than 3 months of age with a febrile UTI; significant dehydration, appear toxic, pyelonephritis, urinary stents or other urinary foreign bodies, renal insufficiency, immunocompromise

Pediatric UTI
* Imaging- (IVP, U/S, voiding cystourethrogram)
o all girls less than 5 years of age
o all boys regardless of age
o children with evidence of pyelonephritis
o any female >5 years of age with recurrent UTIs
o those not responding to antibiotics
o Evidence for these recommendations is only fair
o Study all patients with culture-proven UTIs with a voiding cystourethrogram (VCUG) and a renal and bladder ultrasound

Sexual Assault
* Presentation
o Most often, several years have elapsed
* Symptoms
o Disclosure-
o GU symptoms- vaginal discharge, vaginal bleeding, dysuria, urinary tract infections, urethral discharge
o Behavior disturbances- excessive masturbation, genital fondling, sexually provocative behavior, encopresis, regression, nightmares
o Unrelated complaints in 15%- abdominal pain, asthma, sore throat
* Assailant known to the child in > 90 % of cases
* Definite physical findings are present in only about 50% to 60%
o True in cases of known penetration
* Hymen-
o Most often annular, crescentic, and
smooth edged
o Variation in orifice based on age, size,
position, degree of relaxation
* Hymenal trauma
o Notches, also referred to as concavities or clefts
+ Concavities at the 6:00 position associated with prior penetrating trauma
o Scarring- marked alteration in the vascular pattern (white areas or swirling vascularity) suggests healed injury
o Erythema is not specific for abuse

Sexual Abuse
* Genital examination can be confined to a careful inspection of genitalia, perianal area unless older adolescent or perforating vaginal trauma
* Exam, data collection useful up to 72 hours
* Position- seated parent’s lap, supine in frog leg, knee chest
* Toluidine blue dye applied to the genital area may also detect subtle acute
injuries
* Hymen- fine reddish-orange, thin-edged
* Thickness, color of the hymen vary with age
o Normally thick during infancy, again with the onset of puberty
o In between, thinner, usually annular or crescentic, smooth edged
o Wide variation in hymenal orifice size
+ vaginal opening greater than 4- 5 mm is suggestive of abuse
o Erythema is not specific for abuse

Normal Hymen
* Traumatic hymenal changes-
o Hymenal notches or concavities especially at 6:00 position
o Gaping openings
o Irregular contour with deep notches
o Scarring with marked alteration in the vascular pattern (white areas or swirling
vascularity
o Absence of physical findings does not preclude abuse
Abnormal Hymen
Sexual Abuse
* Genital exam in young boy typically normal
* Anal exam may be completely normal in the case of either acute or chronic
sodomy
o May see fissures, abrasions, hematomas, thickened rugae, lichenification of anal skin, changes in tone, fingerprint bruises on iliac wing, inner thigh
Abnormal Anus
STD Protection

* Cultures of the throat, vagina (or urethra), and rectum for gonorrhea
* Culture from the vagina (or urethra) for Chlamydia
o Rapid antigen assays are not considered reliable in prepubescent children
* VDRL for syphilis indicated if clinical evidence of syphilis, history of syphilis in assailant, or presence of another STD
* HIV testing should only be done after counseling and if there is reason to suspect infection
Pediatric Genitourinary
* Conclusions
o Obtain culture on all kids less than teen years
o Always examine the testicles in boys with abdominal pain
o Consider ketamine if need exam, repair in ER

Pediatric Urology- Gynecology.ppt

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